Little Acres Learning Academy Emergency Form

Little Acres Learning Academy Child Emergency Form
Fill out the form carefully for registration & Emergency Information for your child
Child's Name
First NameMiddle NameLast Name
Date of Birth
Gender
Allergies/Special Accommodations
Child's Expected Days of Attendance
List all Days
Child's Expected Attendance Times
Time of Arrival/Time of Departure MUST NOT EXCEED 10 HOURS DAILY
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
1. Name of Parent/Guardian & Email Address
Cell Phone Number
Area CodePhone Number
Place of Work & Phone Number
Can Child be Released to this Person? Yes/No
2. Name of Parent/Guardian & Email Address
Cell Phone Number
Area CodePhone Number
Place of Work & Phone Number
Can Child be Released to this Person? Yes/No
1. Other Emergency Contact to Whom Child Can be Released & Phone Number*
2. Other Emergency Contact to Whom Child Can be Released & Phone Number
Ex. Grandma Marge Smith 570-555-5555
3. Other Emergency Contact to Whom Child Can be Released & Phone Number
Ex. Grandma Marge Smith 570-555-5555
Check all that you allow for your child
Administration of First AidSwimming/WadingWalks/TripsTransportation by facilityEmergency Medical Care
Signature/Date
Clear
Signature
Clear
Should be Empty:

Little Acres Learning Academy Child Emergency Form